A Comparison of Treated and Untreated
Male Crossdressers
Jack L. Croughan, M.D.,1,2 Marcel Saghir, M.D.,1 Rose Cohen,1 and Eli
Robins, M.D.1
In an interview study of 70 male members of crossdressing clubs, multiple
comparisons between treated and untreated subjects showed that the two groups
are more similar than dissimilar. The only areas of comparison in which the
treated group significantly differed from the untreated group were in
fantasizing themselves as females while masturbating, having ever engaged in
heterosexual intercourse while crossdressed, currently preferring both
heterosexual intercourse and homosexual behavior while crossdressed, and
having experienced more adverse consequences from crossdressing. Further,
where comparisons are possible, our results are similar to those found in
prior studies. All of the subjects were male and the average age of onset is
prior to 10 years, with virtually all subjects first crossdressing if not in
childhood then by middle adolescence. The course is chronic with only
occasional and usually brief remissions, although there are instances in a
minority of subjects of periods of remission lasting several months to a few
years within the context of more than two decades of otherwise continuous
crossdressing behavior. The interval between onset and first treatment, if
any, is several years. Early in its development, crossdressing is virtually
always associated with sexual arousal and sexual behavior, usually
masturbation. Later, in adult life, it is more frequently associated with
heterosexual intercourse and only rarely with masturbation as subjects
approach middle age. There is a trend toward a more asexual nature to the
crossdressing during late adult life. Crossdressing is infrequently
associated with sadomasochism and not at all with exhibitionism. Rates of
unipolar depression and alcoholism were increased in this sample. The results
do not support a significant positive association between crossdressing and
obsessive-compulsive neurosis. The present study confirms previous findings
that crossdressing lacks a familial component either with respect to
crossdressing itself or in association with another disorder.
This study was supported in part by grant MH 20520-01.
1Department of Psychiatry, Washington University School of Medicine, St.
Louis, Missouri 63110.
2Jewish Hospital of St. Louis, 2165, Kingshighway, St. Louis, Missouri
63110.
KEY WORDS: crossdressers; interview; treatment; diagnosis; family;
transvestism.
INTRODUCTION
The majority of publications on transvestism focus on discussion of
theories of etiology or proposals for classification of crossdressing
behavior. Some reports provide data about patients who have voluntarily
sought treatment or who have been referred by the judicial system for
evaluation. There are two prior series of articles that report on the results
of interviews with subjects who were not selected on the basis of being
patients or court referrals. Rather, they were members of crossdressing
social organizations (Buhrich and McConaghy, 1977; Buhrich, 1976, 1977a, 1978)
or respondents to a request for information in a transvestite publication
(Prince and Bentler, 1972). To our knowledge, however, there have not been
reports that have compared treated and untreated subjects. In addition, there
is a series of reports on the results of personality tests with transvestites
(Bentler and Prince, 1969, 1970; Bentler et al., 1970) that essentially shows
no significant differences between subjects and controls. With the exception
of a few case reports, however, we did not find any studies describing either
the results of systematic psychiatric interview with subjects or the
occurrence of psychiatric illness in their families.
The purpose of this paper is to present comparative results of a personal
interview study of treated and untreated male crossdressers. We want to
determine whether conclusions based on results from prior studies of patients
seeking treatment should be modified to account for differences in results
obtained from subjects who have not sought treatment. In addition, we present
information about psychiatric diagnoses in these subjects and their families.
METHODS OF PROCEDURE
Subjects either were a member of one of two national organizations of
crossdressing social clubs or were referred as nonmembers by a member of one
of the clubs. The clubs provided their members with advice and emotional
support for crossdressing as well as a means of socialization.
Exclusion criteria prior to interview eliminated homosexual drag queens
and those who had received a transsexual conversion operation. Subjects
denying these exclusion criteria were systematically interviewed using both
closed and open-ended formats and were asked questions regarding the following
areas: demographic characteristics including age, marital status, usual and
current occupation, annual income, and residence; medical histories including
a review of systems, hospitalizations and operations, and psychiatric
hospitalizations; and symptoms of psychiatric illnesses including anxiety
neurosis, hysteria, phobic neurosis, obsessional neurosis, depression, mania,
alcoholism, drug abuse, antisocial personality, and schizophrenia.
Psychiatric diagnoses were made using specific criteria (Feighner et al.,
1972).
Subjects were also asked about family histories of psychiatric illness
including nervous breakdowns, attempted suicides, completed suicides,
alcoholism, frequent trouble with the law, drug abuse, and sexual problems
including homosexuality and crossdressing. Subjects were asked about
environments of rearing including presence and absence of parents, broken
homes by separation, divorce, and death, and global assessments of the
subjects' opinions about the degree to which they were happy during childhood
in that environment. They were also asked questions concerning discipline and
role modeling for each parent or parental figures. Specific arrest histories
were obtained including types and frequencies of arrests relating to sexual
problems. Questions relating to early childhood traits including sissiness
and early thoughts regarding gender dysphoria were asked.
Subjects were also asked questions with regard to thoughts and behaviors
relating to transsexualism. Extensive data were obtained regarding onset and
characteristics of crossdressing as well as the association of this behavior
with sexual arousal, masturbation, and heterosexual and homosexual behavior.
Information about articles of clothing or accessories used, frequency of the
use, fantasies associated with crossdressing, and awareness of parents,
siblings, wives, children, and friends with regard to the subject's
crossdressing were ascertained. Questions were asked regarding the
relationship of alcohol and drug use to crossdressing and the extent to which
crossdressing had directly or indirectly interfered with subjects' jobs,
marital and family relationships, and other social relationships. Subjects
were asked about the extent to which they had sought medical and psychiatric
help for problems relating to crossdressing and the extent to which they had
experienced remissions and exacerbations of crossdressing and related sexual
behavior. A life history of heterosexual and homosexual experiences was
obtained both in association with and in dependent of crossdressing.
RESULTS
A total of 70 males were interviewed. Club members accounted for 85% of
the subjects, with 60% from one club and 25% from another The other 15% of the
subjects were not members of any crossdressing organization or club. They
were referred for interview by members of the two organizations.
Table I. Sociodemographic Characteristics
Treatment No treatment
(N = 34) (N = 36)
Average age at interview 41.9 42.9
Current marital status
Married 50% 61%
Divorced 30% 14%
Single 21% 25%
Religion of rearing
Roman Catholic 21% 19%
Protestant 62% 69%
Jewish 6% 8%
None 12% 3%
Current SMSA
Los Angeles 15% 31%
San Francisco 21% 22%
Chicago 26% 25%
Denver 15% 3%
Other Midwest Area 18% 8%
Refused 6% 3%
Foreign 0% 8%
Highest educational level
Attended high school 9% 6%
Graduated high school 53% 64%
Graduated college 26% 25%
Graduated professional/graduate school 12% 6%
Occupational rank
Unskilled 9% 11%
Semiskilled 6% 11%
Clerical 9% 23%
Skilled 38% 29%
Professional/managerial 38% 26%
Annual income (1972)
$6,000-9,999 21% 22%
$10,000-14,999 23% 28%
$15,000-19,999 23% 19%
$20,000-29,999 18% 8%
$30,000-50,000 12% 11%
Unemployed 3% 1l%
Table II. Onset and Frequency of Crossdressing
Treatment No treatment
(N = 34) (N = 36)
Average age at onset 8.3 11.3
Full or partial crossdressing
once/week or more at
< 10 years old 29% 19%
10-19 years old 56% 47%
20-29 years old 53% 56%
> 30 years old 71% 58%
Past one year 80% 86%
Subjects were separated into treated and untreated subgroups for comparison
purposes. A subject was placed into the treated group if he had on one or
more occasions been seen by a physician, counselor, or other mental health
professional for problems relating to his crossdressing. Duration, extent,
and results of treatment were not used in determining allocation to the
comparison groups. Using the above definition, 34 subjects (49%) were placed
in the treated group and 36 subjects (51%) in the untreated group. Half of
those in the treated group were self-referred for treatment (N = 17), the
other half primarily sought help as a consequence of legal pressures by the
courts (N = 6) or requests by wives (N = 7), parents (N = 2), or friends (N =
2).
The sociodemographic characteristics of the subjects are displayed in Table
I. The sample is of middle age and 95% white. Approximately one out of four
had never married and most had been reared as Protestants. The subjects are
of higher than average educational level and occupational rank, with higher
than average income. There were no significant differences between the
treated and untreated groups.
Table II provides information about age of onset and subsequent frequencies
of crossdressing. The difference in average age of onset between the treated
and untreated groups is not significant. All but four subjects (6%) first
crossdressed by age 14 years. About half of each group wore just
undergarments the first time, whereas about 10% in each group were fully
dressed. The remainder dressed in varying combinations of clothes at onset.
Both groups (treated and untreated) reported similar frequencies of
crossdressing during subsequent 10-year intervals.
Table III. Masturbation, Fantasies, and Crossdressing
Treatment No treatment
(N = 34) (N = 36)
(%) (%)
Proportion of subjects who masturbated
while crossdressed during adolescence 88 69
Every time crossdressed 40 36
A majority of the times 17 24
A minority of the times 43 40
Predominant fantasies during masturbation
while crossdressed as adolescenta
Crossdressing self 12 14
Self as female 29 6
Heterosexual thoughts 29 25
Homosexual thoughts 0 3
No fantasies 29 53
Proportion of subjects who masturbated
while crossdressed as an adult 88 69
Every time crossdressed 47 52
A majority of the times 23 24
A minority of the times 30 24
Predominant fantasies during masturbation
while crossdressed as adultb
Crossdressing 15 19
Self as female 35 8
Heterosexual thoughts 23 22
Homosexual thoughts 3 0
No fantasies 24 51
ap < 0.06. bp < 0.05.
The frequencies of masturbation with crossdressing as well as the
predominant fantasies associated with masturbation and crossdressing at
different age intervals are shown in Table III. During adolescence, more than
half and beyond adolescence about 3/4 of both the treated and untreated groups
masturbated at least a majority of the times they crossdressed. During
adolescence (p < 0.06) as well as later (p < 0.05) subjects in the treated
group more often fantasized themselves as females than did those in the
untreated group.
The extent to which subjects engaged in various forms of sexual behaviors
while crossdressed are shown in Table IV. Approximately half had engaged in
heterosexual intercourse at some time while crossdressed, whereas about one in
four had participated similarly in homosexual behavior. None had been
involved in exhibitionism in public. There was a trend for more of the
subjects in the treated group to have ever engaged in the sexual behaviors
listed while crossdressed, with a significant difference between the groups
for heterosexual intercourse (P < 0.05). Within the year prior to the
interview, the differences between the groups with regard to preferred sexual
activity while crossdressed were also significant (p < 0.05). Most of the
treated group preferred heterosexual intercourse, whereas about half of the
untreated group preferred no sexual activity.
Table IV. Sexual Behavior and Crossdressing
Treatment No treatment
(N = 34) (N = 36)
(%) (%)
Proportion of subjects who engaged
in some form of sexual behavior
while crossed-dressed 97 92
Masturbation 94 83
Heterosexual intercoursea 62 36
Homosexual behavior 32 22
Sadomasochism 6 3
Current preference while crossdressedb
Masturbation 3 3
Heterosexual intercourse 59 42
Homosexual behavior 12 0
Any of above 0 8
No sex 26 47
ap < 0.05. bp < 0.05.
Table V. Current Precipitating Factors within Past Year
Treatment No treatment
(N = 34) (N = 36)
(%) (%)
Seeing clothing 21 17
Depressed, bored 12 6
Feeling good 0 8
Tension, conflict 15 14
Desire for sexual arousal and relief 0 11
None 53 44
Table VI. Nonsexual Psychiatric Diagnoses
Treatment No treatment
(N = 34) (N = 36)
(%) (%)
Anxiety neurosis 9 3
Obsessional neurosis 3 8
Significant interference 0 3
Mild, occasional interference 3 6
Depression, unipolar 35 25
Definite 24 19
Probable 12 6
Alcoholism 26 22
Definite 18 11
Probable 9 11
Additional heavy drinkers 6 11
Drug use 26 19
Marijuana only, psychological dependence 3 3
Polydrug (nonnarcotic), no interference 24 17
Antisocial personality 18 8
Definite 6 6
Probable 12 3
Undiagnosed Paranoid schizophrenia 6 3
Table VII. Family History of Psychiatric Diagnosis
All family members
combined
Father Mother Brothers Sisters Treatment No treatment
(N = 69) (N = 69) (N = 62) (N = 73) (N = 143) (N = 130)
(%) (%) (%) (%) (%) (%)
Depression 3 7 5 4 6 4
Schizophrenia 3 - - - - -
Alcoholism 14 4 5 - 9 5
Sexual deviations 1 - 7 1 - -
Crossdressing 1 - 2 1 1 < 1
Homosexuality - - 5 - 2 -
First-degree family members
> 1 above diagnoses 25 12 16 6 - -
Total - - - - 18 10
As shown in Table V, only about half of the subjects reported that there
were factors in the prior year that they felt increased their desire to
crossdress. Of those who did report one or more factors, however the majority
reported that the sight of women's clothing often provoked and increased their
desire to crossdress. The treatment group more often reported a form of
dysphoric mood (depression, boredom, tension, conflict) as a precipitant,
whereas the untreated group more often reported an increased desire to
crossdress in association with feeling good or a desire for sexual arousal and
relief. The differences approached but did not reach significance (p < 0.10).
All but two of the subjects had tried to stop crossdressing on at least one
occasion. However, over half of both groups tried stopping only once in their
lifetime, and less than 30% in each group tried three or more times. There
were no differences between the treated and untreated groups regarding
abstinence from crossdressing. The longest average period of abstinence for
both groups was about 1 year.
The extent to which subjects reported nonsexual psychiatric diagnoses are
shown in Table VI. Some subjects received more than one diagnosis. All
diagnoses were made on the basis of lifetime prevalence (Feighner et al.,
1972). The frequencies of unipolar depression and alcoholism were elevated.
Mild increases in antisocial personality and possibly also paranoid
schizophrenia and obsessional neurosis were observed (Goodwin and Guze, 1979).
Table VII shows the lifetime prevalences of these same psychiatric
disorders as well as the sexual deviations in first-degree family members.
The data do not reveal any evidence for crossdressing as a familial disorder.
In addition, there was no significant increase in homosexuality. The usually
observed general population prevalence ratios for males and females of 1:2 for
depression and 3-5:1 for alcoholism were observed in this family history data
also (Goodwin and Guze, 1979).
The proportions of subjects who experienced a variety of adverse
consequences of crossdressing are shown in Table VIII. Subjects were recorded
as having adverse consequences if they had been arrested, divorced, had
experienced some significant interference in their occupation, education, or
social relationships with others, or had experienced negative thoughts because
of crossdressing. Categories were not mutually exclusive. In all, over 95%
had either experienced at least one of the consequences listed or had sought
treatment specifically for their crossdressing behavior. Treated subjects
reported that they had experienced significantly more adverse consequences
than subjects who had not sought treatment (P < 0.05).
Table VIII. Adverse Consequences of Crossdressing
Treatmenta No treatmenta
(N = 34) (N = 36)
(%) (%)
Arrested Crossdressing 38 8
Child molestation 3 0
Divorce 27 8
Interfered with occupation 24 8
Interfered with education 18 3
Interfered with social relationship
with other men 62 28
Interfered with social relationship
with women 41 17
Subject objects 24 8
Family objects 62 53
Has lost friends 18 14
Other object 74 36
Feels guilty 18 25
ap < 0.05
DISCUSSION
All of the subjects interviewed were males. None of the clubs had female
members, although wives of members were often encouraged to accompany their
husbands to the meetings and to club functions as guests. We are not aware of
analogous crossdressing organizations that provide similar opportunities to
females. This might be because of lack of need. It is much more possible in
our culture for women to wear obviously masculine clothing without fear of
recrimination. Thus, the need for mutual support and advice as well as a
protective environment may be nonexistent for females who prefer to wear more
masculine clothing. Also, possibly because of biologically or culturally
induced differences in mechanisms of sexual arousal in males and females,
there does not appear to be a female entity of crossdressers corresponding to
males who crossdress for sexual arousal and relief. Such women are either
rare, nonexistent, or simply do not bring attention to themselves by seeking
help, experiencing interference, or coming into significant conflict with
their family, friends, or society. Those females who do crossdress and seek
help or experience conflict are reported to be either homosexual or
transsexual (Lukianowicz, 1959a; Randell, 1959; Benjamin, 1966; Lester, 1975).
None seem to correspond to the group of heterosexual males who crossdress
primarily for purposes of sexual arousal.
Regarding other sociodemographic characteristics, the data in Table I
illustrate the fairly broad range and distribution of the variables described
for the treated and untreated samples. Comparable information has been
previously reported (Turtle, 1963; Buhrich and McConaghy, 1977; Buhrich,
1977a, 1978; Prince & Bentler, 1972), although our sample was 2-5 years older,
somewhat more often married, and of slightly higher socioeconomic status.
Except for cases of crossdressing associated with psychosis (Ward, 1975;
Lukianowicz, 1959a, 1962), all authors report an early age of onset
(Lukianowicz, 1959b; Buckner, 1970; Benjamin, 1966; Stoller, 1968; Turtle,
1963; Randell, 1975; Prince and Bentler, 1972), on the average by 10 years of
age and almost always by 15. None of the four subjects in the current study
whose crossdressing began after adolescence, however, was diagnosed as
psychotic.
A comparison of the frequency of crossdressing at different age intervals
did not reveal any significant differences between the treated and untreated
groups. The slightly higher proportions prior to 20 years for the treated
group is probably a reflection of the earlier age of onset. Exact comparisons
with other reports are compromised because of differences in data-reporting
formats. However, a fairly specific comparison is possible between Buhrich's
data on crossdressing frequencies in the prior 2 years (Buhrich & McConaghy,
1977) and our frequencies in the prior 1 year. Of the subjects in the present
study, 64% engaged in full crossdressing and 59% in partial crossdressing on
at least a weekly basis during the 1 year prior to interview. Corresponding
figures for full and partial crossdressing from Buhrich's study are
significantly lower, 29% for each.
Regarding sexual arousal and behavior associated with crossdressing,
Buhrich reported that all of his subjects had shown arousal to women's
clothes. (Buhrich & McConaghy, 1977). Five of our subjects (7%) denied ever
experiencing arousal with crossdressing. These same subjects also denied any
sexual behavior, including masturbation, hetero- or homosexual activities, and
other forms of sexual or sexually related behavior such as sadomasochism,
child molestation, rape, or exhibitionism, while crossdressed.
Manifestations of arousal most often involve masturbation or heterosexual
intercourse. Of the subjects in the current study, 79% reported masturbating
with crossdressing during adolescence or as an adult. The comparable figure
for the period of adolescence from Buhrich's study is 53% (Buhrich &
McConaghy, 1977). All but four of our subjects (6%) had masturbated at some
time while crossdressed. Nearly half of our subjects (49%) had engaged in
heterosexual intercourse while crossdressed, and about one in four (27%) had
participated in some form of homosexual behavior on at least one occasion
while crossdressed. There were 4% who had participated in sadomasochistic
behavior while crossdressed. Comparable figures were not found in Buhrich's
(Buhrich McConaghy, 1977) or other reports.
Within the year prior to interview, 37% of our subjects stated that they
preferred not to engage in any sexual activity. This occurred predominantly
in the untreated group and in older subjects. Buhrich reported; similar
observation of a decrease in arousal as subjects aged, with somewhat lower
figure of 27% reporting no arousal in the previous months (Buhrich and
McConaghy, 1977; Buhrich, 1977a). The fact that Buhrich's subjects were, on
the average, 3-4 years younger might partly explain his lower figure.
With the exception of isolated cases associated with episodes of psychosis
(Lukianowicz, 1959b; Ward, 1975), the course of crossdressing is consistently
described as chronic and unremitting (Lukianowicz, 1959b Buhrich, 1978;
Lebovitz, 1972). This was certainly evident in the present study, where, on
the average, subjects had been crossdressing with few exceptions on at least a
weekly basis for over two decades, with occasional brief periods of remission
usually lasting from a few months to a few years. A comparison with Buhrich's
data (1978) reveals that 54% of his transvestites attempted to discard
permanently all their women's clothes with 40% discarding them on more than
one occasion. Corresponding figures from the present study are 83% and 53%.
Buhrich also comments that his subjects invariably began crossdressing again
usually within several weeks. As previously noted, our subjects were somewhat
older and, thus, would have had more time in which to try to stop
crossdressing, thereby perhaps explaining in part our higher percentages.
Treatment appeared to play virtually no role in bringing about periods of
abstinence This might have been a consequence of both the types of treatment
employed and the duration of behavior. Most of the subjects received
psychotherapy alone. This approach has not been found to be very successful;
instead, electric aversion has been advocated (Marks et al., 1970). Further
more, the average elapsed time between onset and first treatment for those who
received treatment was about 20 years, perhaps making their behavior more
fixed and resistant to change.
Regarding possible associations of crossdressing with other psychiatric
illnesses, we did not find other studies using systematically applied
diagnostic criteria for nonsexual psychiatric disorders. There are isolated
reports of crossdressing behavior accompanying the course of schizophrenia and
manic-depressive illness (Lukianowicz, 1959b, 1962; Ward, 1975). Benjamin
(1966) comments that the presence of psychotic behavior and frequency of
diagnoses of psychosis including schizophrenia were observed in, at most, 6-8
patients out of 150 male crossdressers. Bentler et al. (1970) comment, on the
basis of projective tests, that transvestites do not score like
schizophrenics. However, he also interprets his findings as indicating that
his subjects might have a latent thought process disturbance. Crossdressing
associated with delusions of menstruation and pregnancy have also been
mentioned (Lester, 1975, p. 169).
In addition to these comments on crossdressing and psychosis, there are a
few reports about possible associations with nonpsychotic disorders. A
possible association of crossdressing with obsessive-compulsive neurosis has
been discussed many times (Slater and Roth, 1969; Lester, 1975; Lukianowicz,
1959a; Randell, 1975; Buhrich, 1978). Lukianowicz (1959a) and Randell (1975)
have also remarked that crossdressing has been described as being infrequently
associated with psychopathy. Benjamin (1966) writes that his subjects' rate
of alcoholism was low.
In the current study, there was an increase of both unipolar depression and
alcoholism compared with general population prevalences for these disorders.
There might also have been mild increases of sociopathy, obsessional neurosis,
and schizophrenia in our subjects (Goodwin and Guze, 1979). Thus, our
findings appear to be consistent with prior reports in that there does not
appear to be any obvious relationship between crossdressing and other
nonsexual psychiatric diagnoses. The only category that was increased in our
sample but not commented on in prior reports was depression. Dysphoria (i.e.,
a negative mood state) was reported as a precipitant of crossdressing, but
depression as a syndrome seems unlikely as an etiological factor. The onset
of crossdressing in virtually all of the subjects preceded the onset of
depressive illness. Beyond etiological considerations, however, the observed
rates of depression and alcoholism in our sample suggest a need for treatment
of these disorders.
There are two reports of instances of familial transvestism (Liakos, 1967;
Buhrich, 1977b). In the present study, there were three subjects who had one
first-degree family member each, a father, sister, and brother, who was also
reported to have crossdressed. Other authors have commented on the
nonfamilial character of crossdressing (Randell, 1975; Buhrich and McConaghy,
1977; Buhrich, 1977a; Friedemann, 1966; Edelstein, 1960). Family history data
in the current study also failed to substantiate a positive association
between crossdressing and other psychiatric disorders.
Regarding the adverse consequences experienced by our subjects, the data
suggest that subjects receiving treatment for crossdressing experience or at
least report more problems associated with crossdressing. We are not aware of
other reports in the literature with comparable data.
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